Albany, New York: (518) 438-0505

Medical History Form

Patient Name:
Primary Care Physician:

Hospitalization / Surgeries:

Medical Conditions

High Blood Pressure: Yes No
Heart Murmur: Yes No
Mitral Valve Prolapse: Yes No
Heart Bypass Surgery: Yes No
Heart Attack: Yes No
Pacemaker: Yes No
Asthma: Yes No
Stroke: Yes No
Diabetes: Yes No
Skin Cancer: Yes No
Cancer: Yes No ( If Yes, Type: )
Transplant: Yes No ( If Yes, Type: )
Family History of Melanoma: Yes No
Date of last Tetanus shot:

Medication List

Do you take blood thinners? Yes No
Medications you are currently taking:

Do you take Aspirin daily? Yes No
Do you use Alcohol? Daily Socially Never
Do you smoke? Yes No